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Home My WebLink About0069 FERNBROOK LANE Cv 9 fern b'roa k °,L,a,»e ,�, 4 �� i e r r e � � a o _ U � .. o a � � ,. Q, n._ �-� _ m,. LOT 20 p S62' 1'45'E 184.67' lb p 19.z ,ill AWK O :O ti 4.D LOT No w L. 2 x So n? s o' 19 ��, p i DECK fsR p 28.3' `1 13.3' i N62 91'451 148. 77' LOT 22 RES. ZONE- 'RC-2" This MORTGAGE INSPECTION TOWN: �E1Y�7�yjj, Plan is For REGI : STx — STRY OWNER: P '�C an .Use on DEED REF l FLOOD ZONE. "C" l DATE: _ 8 _ z-- —BUYER: ILRQY _ I HEREBY CERTIFY TO 1YQBTH PLAN REF: C 14972—E 6N_MQBT�dGE _SCALE:l 40 -- SHOWN ON THIS PLAN Ig _ — r�, p — --_FT, __THAT THE BUILDING a ," £aFxf't, SHOWN AND THAT ITS POSIT pH E OES THE GROUND AS ::re`�� YANKEE SURVEY` TO T E ZONING LAW SETBACK R QUIREMENTSCONFORM .• CONSULTANTS IT DOES_ NO ��NS __ _ _ OF THE Af r d 4 AREA AS SHOWN LIE WITHIN THE PECIAL —AND THAT r°��.; a'°Y3 OB (SUITE 1) ON THE H.U.D FLOOD HAZARD ,�•,; r, INDUSTRY ROAD 250001 AP DATED_ __ '�V1, �gi ,t4 d r MARSTONS 08 .0 "�� , MI PA(?L A. 7'EL 4 � MA, 02648 PLAN NOT �4! ldliti 28—0055, FA} 4 SURVEY NOT TO BE USED FOR FENCEUMENT 20-5553 `�-- _ S ETC. 250.9n „ ,_ • TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2 0 8/0 8 5/017 Parcel Application # Health Division Date Issued UJIS- Conservation Division �1�- Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 69 Fernbrook Village Centerville ma 02632 Owner John & Lynn Shields Address 69 Fernbrook Telephone 508-775-6000 Permit Request Rebuild existing deck and add aconnector deck niece i Square feet: 1 st floor: existing 17 2 7proposed 0 2nd floor: existing 13 5 7 proposed 0 Total new Zoning District RC-2 Flood Plain Groundwater Overlay Project Valuation 4, 000.00 Construction Typewood Frame ` Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family J] Two Family ❑ Multi-Family (# units) b Age of Existing Structure 30 Historic House: ❑Yes J7 No On Old Kings Highway:,❑Yes-❑ No Basement Type: ❑ Full ❑ Crawl ®Walkout ❑ Other Basement Finished Area (sq.ft.) n Basement Unfinished Area (sq.ft) 17 r� Number of Baths: Full: existing 3 new 0 Half: existing 1 new 0 Number of Bedrooms: 4 existing 0 new Total Room Count (not including baths): existing 9 new 0 First Floor Room Count 5 Heat Type and Fuel: M Gas ❑ Oil ❑ Electric ❑ Other Central Air: Ll Yes ❑ No Fireplaces: Existing 1 New 0 Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: W existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Northern Colony Builders LLC Telephone Number 508-400-7075 Address 180 High Street License # Cs 053638 Home Improvement Contractor# 167739 Emaildabwbcc@comcast.net Worker's Compensation # 500-5012280 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE <� DATE S 1 ( E5 J r FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED :r MAP 7 PARCEL NO. C- r 5 ADDRESS VILLAGE OWNER t t` DATE OF INSPECTION: FOUNDATION FRAME INSULATION _z FIREPLACE ELECTRICAL: ROUGH FINAL .v t E� PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 'ry. Il FINAL BUILDING u 03 DATE CLOSED OUT K A!SOCIATION PLAN NO. I Town of Barnstable - °" Regulatory Services MASS. Richard V.Scali,Director 039. `0� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, John Shields , as Owner of the subject property hereby authorize Northern Colony Bu ,ld'e.rs `LLC. to act on my behalf, in all matters relative to work authorized by this building permit application for. 69 Fernbrook Lane Centerville MA (Address of Job) " "Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. SjgLture of Owner Signature o plican , John Shields ', Daniel Gallagher Print Name, Print Name 5/11 /15 , Date Q:FORM&O WNERPERMISSIONPOOLS Town of Barnstable Regulatory Services ��o�zHE roty,� Richard V.Scali,Director Building Division * u mass.MASS. Tom Perry,Building Commissioner 9Q� 1639- �� 200 Main Street, Hyannis,MA 02601 www.town.barnstable ma us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by sever•aI towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFII.ES\FORMS\building permit forms\EXPRESS.doc Revised 061313 ' the c;omnwnweatnt oimassacnuseus Deparhnent of Industrial Accidents Oise of lmesfigations ` 600 Washington Street Boston,ALA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit:BOders/Contractors/Electricians/Plmnbers Applicant Information PIease Print Leeibly Name(Business✓owmiration/fndMaaI): N o r�h r n o 1 o n y B u i 1 d P r•G r,I. Address: 180 High Street city/State/Zip: W B a r n s t•a h•1 P Ma n 2 ti 6 g Phone#: 50E _Ann-7075 Are you an employer?Check the appropriate bow Type of project(requured): 1.[2 I am a employer with 1 ; 4. I am a general centractor and I employees(fall and/or part-time). * have hired the sub-contractors 6 ❑New constraction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have 8. []Demolition working for me in any capacity. employees and have workers' 9. ElBuilding addition [No workers'comp.insurance comp,insurance# required.] 5. F1 We are a corpm-atim and its 10.❑Electrical repairs or additions officers have exercised thew 3.❑ I am:a homeowner doing all work ' 11.❑Plumbing repairs or additions myself-[No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t to 152,§1(4),and we have no employees.[No workers' 13.�Other aPe-k comp,insurance req[.Ilred.] *Any-applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infDrmation. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating such. $Conhaetors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the soh-contractors have employees,they mnstprovide their workers'comp.policy number. I am an employer f zat is providing workers'compensation insurance for my employees. Below is the policy and job site information Insurance Company Name: Southeastern Ins Policy#or Self-ins.Lie.# 5 0 0—5 01 2 2 8 0—2 01 3 Expiration Date: 5/11 15 Job Site Address: 6.9 Fernbr000k - City/State/T=i Centervill Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,5DO.D0 and/or one-year imprisonment,as well as civ7..penalties in the form of a STOP WORK-ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DU for insurance coverage verification. I do hereby certify under fk air dpenalfies.0 erjwy that the information provided above is true and correct S' Dais: 5/1 1 /1 5 Phone#: 508-400-70 45, Official use only. Do not write in this area,to be completed by city or town official 'City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions- Massachusetts General Laws chapter 152 requires al employers to provide workers'compensation for their employees. Pursuant to ibis statute,an enpfvyee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in'a joint enterprise,and including the legal representatives of.a.deceased employer,or the receiver or trustee of an individual, arts association or other le 1 employees.ees. However the partnership, ��3'�employing�P Y owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter-152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance-or renewal of a license or permit to operate a business or to construct buildings in the camunonwealth for any applicant who has not prodaced.acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealthnor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contrasting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking time boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required.. Be advised that ties affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should be retumed to time city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call She Department at the mmmber-listed below. Self-insured companies should enter their self-insdran ce license number on time appropriate line.' City or Town Officials Please be sure that the affidavit is complete and printed legibly, The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submif multiple p=aWlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in ' (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future parmi or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not:related to any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would hke to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call ' The Department's address,telephone and fax number: ThD C=nonialth of Massachusftts Dapartmeat of Industrial A6ddmts Office of Tnvestigatiaus- f0U W&gdDgtQ,1X Sft-Qet. Boston,MA 02111 Tc,-1,#f 17-727-4900 Wd 406 or 1- TMASSAFE Revised 4-24-07 Fax#617-727-7749. WW .Mass.gWdia ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/OD/YY(Y) 07/28/20.14 'PRODUCER 508.997.6061 FAX 508.990.2731 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Southeastern Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 439 State Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 79398 North Dartmouth, MA 02747 INSURERS AFFORDING COVERAGE I NAIC# INSURED Northern Colony Building Co LLC INSURERA: Arbelld Protection Insurance 141360 P.O.Box 278 INSURERB: Merchants Insurance Group W. Barnstable, MA 02668 INSURER c: AEIC INSURER D: j I INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY E PIRATION. LIMITS L7R INSRD TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YYYY DATE MM/DONYYY GENERAL LIABILITY 8500059899 07/08/2014 07/08/2015 EACH OCCURRENCE j $ ' 1,000,0001 nCOMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 300,000 CLAIMS MADE X OCCUR MED EXP(Any one person) 1 $ 5,00 A PERSONAL&ADV INJURY s 1,000,000 GENERAL AGGREGATE $ 2,000,0001 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s 2,000,000 POLICY PE LOC AUTOMOBILE LIABILITY MCA7013965 01/05/2014 01/05/2015 COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO 1,000,000) ALL OWNED AUTOS BODILY INJURY $ j nX SCHEDULED AUTOS (Per person) B �—{ HIRED AUTOS BODILY INJURY (Per accident) $ n NON-OWNED AUTOS I F1 PROPERTY DAMAGE $ �—; (Per accident) GARAGE LIABILITYAUTO ONLY-EA ACCIDENT $ nANY AUTO OTHER THAN EA AC �I AUTO ONLY: AGG S EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ �I OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ _ $ WORKERS COMPENSATION WCC-500-5012280-2013 07/08/2014 07/08/2015 TORY LIMITS X ER _ AND EMPLOYERS'LIABILITY Y ANY PROPRIETOR/PARTNER/EXECUTIVE� E.L.EACH ACCIDENT $ _ 1,000,000 C OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 1,000,00C SPECIAL PROVISIONS below OT HER l I • I DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN Town of Barnstable NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Building Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Main Street REPRESENTATIVES. Hyannis, MA 02601 AUTHORIZEDREPRESENTATIVE I Karen Bernier ACORD 25(2009/01) FAX: 508.790.6230 C 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety �"Board of Building Regulations and Standards . : Construction Supcii isor.j License: CS-053638 .� F DAMEL J GALL81G• PO BOX 278 = ' x West Barnstable IOIA,•�� Expiration 10/27/2015 Commissioner• .. R 6�e - Office of Consumer Affairs and Business Regulation n 10 Park.Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cractor Registration Registration: 167739 Type: LLC ( ; �7 Expiration: 10/25/2016 Tr# 264780 NORTHERN COLONY BUILDERS LLC DANIEL GALLAGHER P.O. BOX 278 WEST BARSTABLE, MA 02668 - / — - ---- ------ --_--- Update Address and return card. Mark reason for change. i_ I Address Renewal Employment Lost Card 3CA 1 20M-05/11 V�G' �0497g12MG[I{BCLGG{Z d�U(�GU,J000C�[UJG'C�iJ Office of Consumer Affairs&Business Regulation. License or registration-valid for individul use only 2RTLWiOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation �rRegistration: < 67739 Type: 10 Park Plaza-Suite 5170 '7 Expiration_-1s%2_5720^1.6 LLC Boston,MA 02116 ' NORTHERN COLONY.,BUILDRS:LLC. F, VO 1 DANIEL GALLAGHER� t� _ ;•/ --y�%% 180 HIGH ST W. BARN, MA 02668 Undersecretary No4,a ' signature i LOT 20 . 0 S62 31'45 T 184.67' i _ tip . O 0 2' ,,�ff�• nWx o 0 Q ti :i 14.0' 0' M LOT w LOT 21 � 6.0, ~ o 1 9 ;n r-') DWx o w 14.o' 0 00 7 0' Dix o~ ~0 28 3' l� N i N62 31'45"W 148. 77' LOT ,22 RES. ZONE- 'h'C-2" This MORTGAGE INSPECTImill ON Ian is For FLOOD ZONE. "C" TOWN: �EIYTE hI.T•F B nk Use Onl DEED REF: S'T�1 9 - — REGISTRY OWNER �M IIZQY_ _ _ _ DATE: 1Q�e,GQB— _ _ —BUYER: _,LOHALT� 41 YN� SHIEZW PLAN REF:-L C_J - -2_ _SCALE:I'= _40__,FT I HEREBY CERTIFY TO NQBTH a��'Rrr_.ey_�QBZG. yANKEE SURVEY ___THAT THE BUILDING 4%K, of r SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS ?¢ � PA�.�L � CONSULTANTS SHOWN AND THAT ITS POSITION DOES ---- CONFORM y A. ' 40B (SUITE 1) TO THE ZONING LAW SETBACK REQUIREMENTS OF THE IMF_;-1rHRq TOWN OF -__RAR9 ,��__—_____-_-_AND THAT 140. sn� INDUSTRY ROAD IT DOES 1VOT_ LIE WITHIN THE SPECIAL FLOOD HAZARD '`� �'Er,,SttaSU MARSTONS MILLS, MA 02648 AREA AS SHOWN ON THE H.U.D. MAP DATED_7/��__ - "�0,4! � � � TEL 428-0055 QQmmianitv- 250001 0008 D FAX 420-5553 THIS PLAN NOT MADE FROM AN INSTRUMENT�AII A M IfiI-I SURVEY, NOT TO BE USED MR FENCES. ETC. 25090 DAF Print Page Page 2 of 4 • Sales History-Map/Block/Lot: 208/085/017-Use Code: 1010 History: Owner: Sale Date Book/Page: Sale Price: SHIELDS,JOHN T&LYNN H 1998-10-15 C150475 $327375 KILROY, PEGGY M 1991-11-15 C 124797 $100 KELROY, PEGGY M& BERNARD T 1986-10-15 C108597 $230000 FRANCO,NICHOLAS D 1985-05-15 C101628 $50000 HOSTETTER, DANIEL C 1983-12-15 C87515 $0 • Photos 208/085/017-Use Code: 1010 • Sketches -Map/Block/Lot: 208/085/017-Use Code: 1010 WDK 2U 35 W�K• L 8BAS,, BAS 6BMT1 BMT' 1 24 3 .24 qL FHS8- GAR, 2 , 17 .24 AsBuilt Card N/A • Constructions Details -Map/Block/]Lot: 208/085/017-Use Code: 1010 Building Details Land Building value $ 269,000 Bedrooms 4 Bedrooms USE CODE 1010 $305,723 Bathrooms 3 Full + lH 0.48 http://www.townofbamstable.us/Assessing/printl5.asp?ap=0&searchparce1=208.085017 5/12/2015 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I A , m / �C(�'J IL DATA } a a . • s ? 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W w Y i i • • M i • i woo " s o m e # o w w a 19 Al as fY el • a rliel wXIN ■e a w s s Y Town of Barnstable *Permit# �� '�..� ' Regulatory Services Fees 6��jrnm issu date r 8ARIZBrAKA ` Thomas F.Geiler, Director r�o " ESS PERMITBuilding Division JUN Tom Perry,CBO, Building Commissioner _ 3 2008 200 Main Street, Hyannis,MA 02601 TOWN OF gqR AB�.E www.town.barnstable.ma.us NST Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY - Not Valid without Red X-Press imprint Map/parcel NumberQ� "_G 1 Property _ p y Address 1609 Ternbrook [Residential Value of Work.___A&,00C Minimum fee of$25.00 for w k under$6000.00 Owner's Name&Address Contractor's Name bavwwll AssoelC�-des Teleplmne Number a: Ca• }4� Home Improvement Contractor License#(if applicable) `L��q Construction Supervisor's License#(if applicable)_ -A ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor VIam the Homeowner have Worker's Compensation Insurance Insurance Company Name ABC a( L Workman's Comp. Policy# (CCU pQ aAsjAb j app Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) [�Re-side ❑ Replacement Windows/doors/sliders: U-Value (maximum .4 *Where required: Issuance of this permit does not exempt compliance with other town department regilations,i.c.I'Iistoric,Conservation.etc ***Note: ert wrier mu gn. roperty Owner Letter of Permis ' n. A c y of the o e Improv ment Contractors License is requ, d. SIGNATURE: Q:Forms:buildingpermits/express. Revise091307 Date: '5/5/20009� Time: 10:03 AM To: M 9,5083626115 Page: 002 Client#:9742 2BAKERAS ACORUM CERTIFICATE OF LIABILITY INSURANCE 0511005/aa°"YYY' PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling&O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Agency ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 973 lyanough Rd., PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC.# INSURED INSURERA: Harleysville Worcester Insurance Co. Baker&Associates,Inc. INSURER B: Associated Employers Insurance Compa P.O.Box 923 INSURER C: Centerville,MA 02632-0071 INSURER0: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE'FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EFFECTIVE POLICY EXPIRATION - LTR INS, TYPE OF INSURANCE POLICY NUMBER OATS MVIID DATE(MWDDIM LIMITS A GENERAL LIABILITY CB831748 04/19/08 04/19/09 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY - DAMAGE TO RENTED PREMISES Me o r $100 000 CLAIMS MADE n OCCUR MED EXP(Anyone person) $5 000 X PC Ded:250 PERSONAL a ADV INJURY $1 000 000 GENERAL AGGREGATE $2 OOO OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $2 OOO OOO POLICY JECT PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea acddent) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per acddenl) - _ .. GARAGE LIABILITY AUTO ONLY-FA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ - - AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ t DEDUCTIBLE $ RETENTION $ - $ B WORKERS COMPENSATION AND WCC5002454012008 04/23/08 04/23/09 X OR IIMIT orH- EMPLOYERS'LIABILnY E.L.EACH ACCIDENT $1 OO O00 ANY PROPRIETOR/PARTNER/EXECUTIVE - OFFICER/MEMBER EXCLUDED? NO E.L.DISEASE-EA EMPLOYEE $100 000 Ifyes,describe under - SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500 000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS . Officers are included under the workers compensation policy. Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of:Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR To MAIL. in DAYS WRWMN Thomas Perry NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 200 Main Street IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Hyannis,MA 02601 REPRESENTATIVES. AUTHORUED R PRESENTATIVE �- e - ACORD,25 Q001108)1' of 3 #S51922/M519.11 LS1 0 ACORD CORPORATION-1988 The Commonwealth of iVassachusetts Department of Industrial Accidents Office of Investigations I^I 1 600 YVashirtgton Street Boston, MA0?111 -gam wwminass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor /EIPlease Print,Lebers ibly A licant Information 1, Name (,Business/Organization/Indivuival): Address:?O-Z City/State/Zip: Ce � J k hone #: `?J Type of project(required): ou an employer? Check the appropiatee bI am a general contractor and INew construction [,Are . I am a employer with _ have hired the sub-contractors employees(full and/or part-time).* Remodeling listed on the attached sheet. 2.❑ 1 ant a sole proprietor or partner- These sub-contractors have [] Demolition ship and have no employees employees and have workers' Building addition working for me in any capacity. comp.insurance.$ [No workers' comp. insurance 0.❑ Electrical repairs or additions 5, � We are a corporation and its repairs or additions required.] officers have exercised their 1.❑Plumbing p 3.❑ I am a homeowner doing all work myself.[No workers' comp. right of exemption per MGL 2, Roof repairs c. 152,§1(4),and we have no insurance required.]t employees. [No workers' 13 Other CJ,d►� comp.insurance required.] J davit *Any applicant that checks box#1 must also fill out the section below showing.their workers'compensation pot cy information. t Homeowners who submit this affidavit in ork and then f re outside contractors mil it submit a new the subcontractors and tate whether or not thosetentities have such. ;Contractors that check this box must attarhed an additional sheet showing the name f provide their workers'comp.policy number. employees. If the sub-contractors have employees,they must P loyee Below is the policy and job site 1 am an employer that is providing workers'compensation insurance for my emp information. t Insurance Company Name: 031 Policy#or Self-ins.Lic.#:0� Expira ' n Date: City/Sta /Zip: 2 Job Site Address: Attach a copy of the workers' compensation policy declaration page(showing the h im ition of criminal y number and ,penalties ration aof a Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to os p fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties histstatement ma beaforwarded STOP Oto h Office of ORDER d a fine of up to$250,00 a day against the violator. Be advised that a copy o Investi ations of the D for insurance cov a verification. I do hereb ce ify Ode a pains nd ena les of perjury that the information pro v ed above is true and correct. Date:- Si t3 Si nature: Phone # o n' `A Official use u►rlr. Do not write in t/11s area, to he completed by city or town officia Permit/License # City or Town: Issuing.authority (circle one): ector 5. Plumbing Inspector i 1. Board nP Health 2. Building Department 3. Cite/Town Clerk �. Electrical I Inspector h. Other Phone #' (;orttact Person: Board of Building Regulations and Standards License Or re isti A11011 Alid 101 111thN JJUI 0-w only - HOME IMPROVEMENT CONTRACTOR before the ex iration date. It found return to Board of Bui ding Regulations and Standards Registration: 118494 One Ashburtm Place Run 1301 Expiration: 2/1/2009 Tr# 126302 Boston,Nla.112108 Type: DBA BAKER CUSTOM ALUM&VINYL INC. MARK BAKER is 521 SHOOTFLYING HILL-RD. CENTERVILLE, MA 02632 Administrator Not valid without Signature Age Board of Building Regulations taidards Construction Supervis e?,,'-I.,/.S, ervs9'i'p License: ;,.u., 74477 sirtma 7 1/6/1973 1!6/2009 Tr# 8139 00 BRETT USSIERE-— REHAM LAK ORE I F=�8�i ET W AREHAM,MA 02538 Commission E r I . :j Town of Barnstable • AEM , Regulatory Services t . 1639. F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Secti n If Using A Builder . I, /1 a r t✓1 ��10' ei:�P , as Owner of the subject property hereby authorize UQ�G 4yc,-,,K.kC�►.. J.Y1G. to act n my behalf, in all matters relative to work authorized by this building permit application f : Cock bGWnbroot-- (Address of Job) GXx) sign a re of Owner date Print Name Q:Forms:buildingpermits/express Revise091307 OF YtlE TOWN OF BARNSTABLE. 2$.66. Permit No. ... . - BUILDING DEPARTMENT { B°M°T TOWN OFFICE BUILDING Cash 'h'D iuY R� HYANNIS,MASS.02601 Bond .....X ,� CERTIFICATE OF USE AND OCCUPANCY Issued to Capricorn Realty Trust Address Lot #21, 69 Fernbrook Lane Centerville, Massachusetts USE GROUP FIRE GRADING OCCUPANCY LOAD THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS,AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ........... .......l..... 19................. ...... . � ..,..a.... .. ....... Building Inspector �''�•o TOWN OF BARNSTABLE BUILDING DEPARTMENT = rAR AN& 1 TOWN OFFICE BUILDING rur. HYANNIS, MASS. 02601 i MEMO TO: Town Clerk FROM: Building Department DATE: An Occupancy Permit has been issued for the building authorized by Building Permit ........n �l�✓,(l »............». ._ ...».»...... . .......»»» issued to /�' /I ,l 0� ....� !��n .................... .» `.. Please release the performance bond. THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) m A , I / �C(�J- L DATA M-77E tilA'b�9LF1-7 _ s °$ht!+'tea '!T ',•sWE& , _ TOWN OF V. ASIE M SSa�Ciill'" .. Cam. •� .:,� t JOB WEATHER CARD DATE 19 ' PERMIT NO. APPLICANT ADDRESS 4. (NO.) ~(STREET) (CONTR'S LICENSE) PERMIT TO " `"`" (_I 'STORY , NUMBER OF DWELLING UNITS X' - - (TYPE OF IMPROVEMENT) NO. (PROPOSED USE) rl, ZONING AT (LOCATION)' DISTRICT IN0.) (STREET) BETWEEN AND " (CROSS STREET) - - . (CROSS STREET) - LOT SUBDIVISION LOT BLOCK SIZE f. pk. BUILDING IS TO'B FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION. TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION .(TYPE) 'REMARKS: - AREA OR y I:Ii PERMIT VOLUME ESTIMATED COST. FEE a (CUBIC/SQUARE FEET) 'OWNER )� ADDRESS BUILDING DEPT BY i THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY-OR SIDEWALK OR ANY PART THEREOF. EITHER�TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED t; Pw FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE'APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS .WHERE APPLICABLE SEPARATE INSPECTIONS REQUIRED FOR PERMITS ARE REQUIRED FOR ALL CONSTRUCTION WORKS CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN ELECTRICAL, PLUMBING .AND I.'FOUNDATIONS`'OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS. - 2. PRIOR TO COVERING STRUCTURAL r QUIRED,SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL ' MEMBERS(READY TO LATH). 3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE. . 00CUPANCY., - - ? ' :.-POST .THIS CARD SO IT IS VISIBLE FROW STREET`' r `e BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS .4 z 2 / 2 ey • 3 HEATING !NSPECTING APPROVALS REFRIGERATION INSPECTION APPROVALS OTHER N E ING o . -. • : �3 vie BOA D OF .: '+LT ircl a+?o:Esu �s.' 7nE? ?ERM(T"WILL BECOME NULL AND 76I'Dft CON$TRLCTIO rP.;PE TION�`,@tYDTt71TE0 NS.PE'C CR ,ie;g aPFROVED M? ' ,r:r�US` - WORK'IS NOT STARTED WITHIN SIX:MOMT(iS OF pATE•7HE' OAS`BE`•ARANGED:F.OR AcEs DF coN� auC*(oN PERpsI_T.15 t55UED A.5 NOTED ABOVE - OR EN'NOT(F� Vw Assessor's ma .and lot number~" �� ." SEPTIC SYSTEM MUST BE THE t INSTALLED IN C o�♦ . OMPLIAN • Sewage Permit number .........:.......�.��--:% � WITH TITLE 5 C `�: ENVIRONMENTAL CODE AN ,: BABHASeTa LE, House number T HIN '0 M 1::. ?�1... ............................................ REGULATIONS ° tb 0 mxf a' A P P R O V E XUaWN . OF BARNSTABLE • $a nstable Conservation 4��Signed Date I L D I N G INSPECTOR APPLICATION FOR PERMIT TO'...........CI?.?1.atxu.Q.t .�S ngle,•Family„Dwelling ;,; ,;. TYPE OF CONSTRUCTION ......... ood Frame - ......... ..................................................................................................... October ` 85 ......................31.....a.................19........ TO THE'INSPEC'TOk OF BUILDINGS: The undersigned' hereby applies for a permit according to the following information: �rt LocationLot 21- Fernbrook-...C� w�x.Y J .1A.......................................................................................:....�............................................ - ProposedUse ............................................................................................................................................................................. Zoning District ..... ........................................................Fire District ........Centerville Osterville ...................................................................... Name of Owner ......Q.apr.i.c4.xxl...Re,a11✓.y...T]ws.I......Address ...7G5,,,Falmouth Roads, Hyanni,s...MA,,, Name of Builder ....k'.rA)AQ.o....R.ea.I... ....Same...................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms .......Eight.............................................Foundation P.C. ...................................................... Exterior .......0 Ix. ...and1or S1 a ngles....... ..:Roofing ...Asphalt Shingles Floors .........Carp.el.............................................................Interior ....SheetrOCk ........................................................................ Heating .....Q4.5....... ................................................Plumbing ....Tyvo — Copper ................................................... Fireplace Yes................................................................Approximate. Cost .... ............................. Definitive Plan Approved by Planning Board � -��'— Ik_ '� . . Z- S Feet ----- -- 19 - Area ®fig r............ Diagram of Lot and Building with Dimensions Fee �._ SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam .. �Cd� •••••••. t r Construction Supervisor's License ...... q `�.. CAPI.ICORN REALTY TRUST tv Yc 28661 Two Story .No ............ Permii43for ... .................. Single FaFnily Dwelling any ............................q -.................................. Lot 21 69 ' ernbrook Lane !............................................ Location .............f5:—! 0 Cent-er-vilij ........................................... t: Capricorn Re4lty Trust Owner .....................4 Frame Type of Constructio' .............................. ... .................................. ........ .................................. Plot ............................ Lot ................................ `fir a Permit Granted ..... .........19 85 Date of inspection .....................................19 Date Cornplejed .... ..............t19 M WTr M M 0 ryFF� r' Assessor's map and lot THE TO�y Sewage Permit number ...................... � gS. ............. . . d Z EAHB9T1►DLE, i House..,an'umber ' - MABa o�O 1639. e�0 O MPY A,. TOWN OF 'BARNSTABLE lollle-� BUILDING INSPECTOR t APPLICATION FOR PERMIT TO ............C4ns$. .1? 1...uingl;e„Farm 1 yvel1 ink ......... - TYPE OF CONSTRUCTION .........V, d...Frame. .................................................................................................. ... ..... ....... ..Oc,tok.er 31,.1.................19.!.J.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ......Lot...21 Fernbrook......Cen.te.r.v1.1.1 e..1,1A.......:................................................................................... ProposedUse ............................................................................................................................................................................. Zoning District ......RC-. ........................................................Fire District .....Centerville Ostervil.l.e ................................I...e.............. Name of Owner ......Caprl.csarx1...ReaI'ty...Trust......Address ....76.5..Fa.IMQ.Ul.h...ROad,,,.j yannis....MA... Name of Builder ....Franco...Real...Es.t.....Dey......C.Q,Ad06s6 ...Z.4I119...................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ........13.1ght.............................................Foundation P.C. .............................................................................. -Exterior .......Clapbnar.d...a.nd/.Or...S11A.x1;;1.QP..........Roofing ....Asphala...Shin€r.1.e.5...................................... Floors ..........CarpE"�Carpet............................................................. Interior ....i .eet .0s...................................... Heating .....Gas...-..F.-11...A..............................................Plumbing ..... ............................................. �; Firepp ..............................Approximate. Cost ....$150 000 0 lace ...........X.�;�................................. ...�.................0 ................................... Definitive Plan Approved by Planning Board I/�_____= _� _19 _ . Area ......Sq. Feet . Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .... r�.. :.�. a.!: r .;� Construction Supervisor's License ...... �C.. CAPRICORN REALTY TRUST A 208-35-17 �74S- - i S-j— f c No 28,�6 Permit for ,,,,Two Story ..... Single Family Dwe`lling`' Location Lot 21, 69...Fe. . ... rn rc ok Lane................ . . .... . ..... Centerville Owner Capricorn Realty t .............................................Trus..................... Type of Construction Frame , ................................................................................. Plot ............................ Lot ................................ Permit Granted .......NQ.veznbP-x'...13........19 85 Date of Inspection ....................................19 Date Completed ......................................19 � T - TOWN OF BARNSTABLE.BUILDING PERMIT APPLICATION. Map A 0 Parcel 08S Q t7` Application # �" Health Division R Date Issued lP 3 Conservation Division 4J . Application Fee Planning Dept. 'o. Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH Preservation/Hyannis Project Street Address OR RC(-n)0 1100 V_ Village Owner jntN,!S'l k,c id S Address Co9 Tem 6n%,\L Cen (" oa( -6a Telephone_Jfl8- -1-7(0 0-6 \a e Permit Request t( 7`I ro u o� % ' CCL tS; uare feet: 1 st floor: existing proposed 2nd floor: existing .q 9 p p g proposed Total new Zoning District Flood Plain Groundwater Overlay Project ValuatioTS OW Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. r Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) V Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing w 72 Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor R qn Coun#- Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woodJesting al stogy ❑is ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ neW4 size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION re (BUILDER OR HOMEOWNER) Name «'_8 Telephone Number 'S09.3GI AA S Address 0 7K"& fy .7 License# f�h Home Improvement Contractor# Worker's Compensation #WC500345AbRo0b ALL CONSTRUCTION DQBRISI RESULTING FROM THIS PROJECT WILL BE TAKEN TO QC'Y1� U GNATURE DATE COII l P� • F 1 FOR OFFICIAL USE ONLY r APPLICATION# - DATE ISSUED I i MAP/PARCEL NO. i I } ADDRESS VILLAGE , OWNER DATE OF INSPECTION: FOUNDATION ? -FRAME '# INSULATION .S FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH i FINAL ' GAS: ROUGH FINAL r k FINAL BUILDING i DATE CLOSED OUT 3 ASSOCIATION PLAN NO. - f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations. 600 Washington Street Boston, MA 02111 ` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Naive(Business/Organization/Individual):3 a Y_er- ASSo C 1 gAe5 Tin c Address:—Po O X Q a 3 City/State/Zip:C' "(`OlIle 1! lAOra(o3a Phone.#: AVlarn ou an employer? Check the appropriate bog: Type of project(required): 1. a employer with 'q 4• ❑ I am,a general contractor and I 6. El New construction employees(frill and/or part-time).;. have lured the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g° ❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers' comp.-insurance comp•insurance.# required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs . insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.�Other��@G�C. comp.insurance required] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. �.t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tcontractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. Ifthe subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. . . Insurance Company Name: . SS C C 1 Q 1'Y1 Policy#or Self-ins.Lic.#: W U 50 oa��go 1 a o 0 A :�t 11,, Expiration Date/. M t'e c-46 b 8 ` City/State/Zip:/State/Zi Ce n CJ►I� 1"1 M G 6;X Job Site Address: t3' P� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition'of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of 4 Investigations of the DIA for insurance coy&'aib verification. I do hereby ce tuer Lepain pen s of perjury that the information provided above is true and correct Si afore: Date: �1 _ Phone#• Sb U' ZG a- fp-AA!,,� Official use o*,Do not.write in this area,to be completed by city or town official City or Town: ;, Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building'Departm_ent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing.Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees: Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written" An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate_a business or to construct buildings in the commonwealth for any applicant who has not produced'acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Co anies LC or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need'only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write"all locations in (city or town)."A copy of the'affidavit that has been officially stamped or marked by the city or town may be.provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ' please do not hesitate to give us a call. The Department's address,telephone-and fax number: +The C6mmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 604 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-977-MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass..gov/dia I Date: 5/5/2008 Time: 10:03 AM To: @ 9,5083626115 Page: 002 Cherd#:9742 2gA ACORD,. CERTIFICATE OF LIABILITY INSURAN E o505Q8 PRODUCER - THIS CERTIFICATE IS ISSUE AS A MATTER OF INFORMATION Dowling$O'Neil Insurance ONLY AND CONFERS NO RIG ITS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE )OES NOT AMEND,EXTEND Agency ALTER THE COVERAGE AFFC RDED BY THE POLICIES BELLOW. 973 lyanough Rd., PO Box 1990 Hyannis,MA 02601 INSURERS AFFORDING COVER kGE NAIC# INSURED INSURERA Harleysville Woroeter Insurance Co. Baker&Associates,Inc. INSURER B: Associated Employ Drs Insurance Compa P.O.Box 923 INSURER C: Centerville,MA 02632-0071 INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY P ERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS MRTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EX LUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE POLICY NUNMR PDATE ff&NDDNYI LIMMS A ORAL uAmurY CB831748 04/19/08 . 04119/09 O CCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY SE TO $100,000_. CLAIMS MADE QX OCCUR An ans oersw: $5 000_, X Pr)Ded:250 L&ADVINJURY $1000000 $2 000(100GEN'L AGGREGATE LIMIT APPLIES PER: S-COMPIOP AGG s21000,000 POLICY "T LOC AUTOMOBILE LINBLnY OMBINEO SINGLE LIMIT $ ANY AUTO a accident) All OWNED AUTOS ODILY INJURY $ SCHEDULED AUTOS at Damon) HIRED AUTOS ILY INJURY $ NON-OWNED AUTOS or accideni) OPERTY DAMAGE $ OF accident) GARAGE LIABILITY OLITO ONLY-EA ACCIDENT $ ANY AUTO )THER THAN EA ACC $ O ONLY: AGG $ EXCESSIUMBRELLJILNBRJ1Y ACH OCCURRENCE $ OCCUR CLAIMS MADE GGREGATE $ DEDUCTIBLE $ WC B WoRKERscaMPENS :rmAND WCC5002454012008 04/23/08 04/23109 I IMIT O R EMPLOYERS'LIABBJTY .L.EACH ACCIDENT $100,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OrFICERIMEIMBER EXCLUDED. NO L,DISEASE-EA EMPLOYEE $100 000 WIf yyes,AL PROVISIONS describe under .L.DISEASE-POLICYPOLICYLIMIT $500 D00 SPECI OTHER -T DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEWNT/SPECIAL PROVISIONS Officers are included under the workers compensation policy. Insurance coverage is limited to the terns,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the {See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBE POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSURER PALL ENDEAVOR TO MARL AIL DAYS WRITTEN Thomas Perry NOTICE TO THE CERTIFICATE HOLDERI AMEDTOTHE LEFT,BUT FAILURE TO 00 SO SHALL 200 Main Street I MK)SE NO OBLIGATION OR LIABILITY C F A MY KIND LWiNI THE INSURER,ITS AGENTS OR i`iyaimis,MA 02601 ENTATIVES. MrTHORM RJPRESENTATIIVE b ACORD 25(2001108)1 of 3 #S51922/M51911 I.S1 m ACORD CORPORATION 1988 �F1HE, Town of Barnstable Regulatory Services vBA ►.E,� Thomas F.Geiler,Director t6.39.�a�` Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 r www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder � 1 Sh I, �'lYl- 1 l , as Owner of the sub'ect property 1 �+ R,�sso ( ^,, 1 p p �'hereby authorize-la W C `� G 1 Q,�CecJ Inc • to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner,is`applying for permit please complete the Homeowners License Exemption Form on the-reverse side. rl-170P KA4Z-0WWPR PRR MI.VZT(1N o ! Town of Barnstable 0,p THE Tp� " Regulatory Services Thomas F.Geiler,Director sAmsrwBr s, : �. MASS. ,�� Building Division PTfD �s Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Rrmv.town.barnstable.ma.us Office: S08-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. - - 'DEFINITION OF HOMEOWNER e Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. '(Section 109.1:1) ! The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official - Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. ;%� �oa�Lnuarturrvt� of �Cii:rxL' uae!!1 Board of Building Regulations and Sto idards. c Construction Supervisor License Licenser CS 74477 BirtHdate: 1/6/1973 Expiration: 1/612009 Tr# 8139 Restriction: 00 BRETT J BUSSIERE' 111 WAREHAM LAKE SHORE C EAST WAREHAM, MA 02538 Commission r 06/10/200U TUw 10: 33 Fax zo'o1/001 ),� •••••••�r • } 1� a ao" ^�':uM1Fy'/,Y,umv:.,.�+r•,:^rCnrry� .. , j�t�. 15,'9, Ian) _.�'�":k�� ,,:,,��``u:�5�(•(.'r-'''t�1 r_.:•,, ','•'.'-� „9t '•??.., '�,c�.:. ..:.'-:n. `�� _- :'r_, ti ..... ^� 11 _',�u {:.. � 1. t.� ,ti;,1 xr. ,.a-.Ik,-;: d76 e)!alt_•^)�;?yh�`"'Ut, 4, a, �'. rlt�'r BUSSIERE BRE7'Il r J � p 1 y x, bt yrh�,�`h J�'a,7FIJ�. � r•1G N ._llp!I��t*M1'::�'H"vS' �;; ,� •Y' _ l.T... t;.�+„^'. +d}y y� � 1H�, �'.,�".��l n. `'�,• ,=ut` + �tir�7� � .:1f�'>t: .,�+," _,:r�.l b��'y' :'7 •r�t(rr 1 9•�i`da �1. ::�`..,, - Lei - ...,aa� b�, ,h,tr� I}:..:'..`7 i' ,,:�,7�.:.�:�:(r•a.:'�,:,,,lf., '}�;77,, !•^ �,,�'r'f','JYk! ,�r ..�:w,1y, r. :,,t:�t,�,. u•r I{�`: ��y�•;r .-�fh;�"^'.e ' :rlif ))��r'1 •,�.'I,;y t. ,} � ".ri�i f, �'�� 1 r 7;..� _ =r•,� ^stir � "- �.�� ..4i.i1,1'ry'1�,�dI M"•�:I{i •.�:"1':.11'�} y,).�ri��l i�fl' r4it�' I- '.t� cry,,, '`! i.4.,�..ri�':'i„ �\'.':'r. .,1,: 'pper:,. ,.� 7' .a ,:ax•, "v:,, ,:ntr.. 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'�: '�,Il.:,rrn•{rntt '.(I flh',:.v'1"'.iL'L':`'�i�u�IlF.r:�..;�'1y� ,l� } ..�r , ,. �.. �„.r. if... u. f' ,,;� r•r ,!"a,.. .�rF;t I,! 'y:;r••,�� r�G I'�N�,➢,',.�',rh��; - . .,,.,• .:JY^, nl`$:•, _ ,Si'.;,,., `rld., ..,h,'.�,�,�''>h. 'f,.1; til 'IRrni � ---- 9 2 : + SHEET 2,10IF2 (set SMN ) �• i /B 17 + s 50oP 20'E �. lei ie �� FERN �w a LA. 1� N 50" ZO w 24 erDe� t s so c 4 fe 1 N Kprf�s �� t N sr•56 w y $ • W � r ym� � ` ` $ C2Z y ►1 s '15r !1 wan 22 �y9Ip fje8 e ^aa ` ly,i to i/on io9.-re 9 t 0.00 h Cori 0450 8 � O rJ � p i 1 0 53o04'ss"w 'all f ku i V1 a, ill 2 ; M4�y E• 8 W i�� Lincoln IR ach. 16 .60 Victor R✓Ato Croaker � « � w OD x- t� 'fig ,i� 8• lrK nrl Qb 3 J o w N it p 1��YUeH nee G Ne A � SmIs of this#m/OV foi V to an inch ao >- i Jr ga3 ly- r t -D _ ... — _.._..w._ _. .. . . . _. . — p . i 1 I BAKER ;BAKER 5 BAKER&ASSOCIATES, _ CUSTOM LIVING s G'�'naorrcr�oN Srac�A�'�s� INC.� I' ', and DESIGN P.O. Box 923 Phone:_ . 508 362 2445 Centerville,MA 02362 Fax: . 508 362 61 15 June 11, 2008 Email:info@bakercapc.com To whom it may concern: Please see attached form from the Commonwealth of Massachusetts Statement of Change of Supplemental Information Contained in Article VIII of Articles of Organization On it defines the Officer and address of Baker&Associates, Inc. It states that Brett Bussiere is the Secretary,of this corporation. It stats that Mark Baker.is president and a director , It states that Carol Baker is Treasure. Please contact me directly if you have any further questions or concerns Sincerely Vanessa Spencer Office Manager s The Best of Cape Cod Living Begins with Your.Home �17e c�outnt�nluealth -o� �t�.a�sachi sett.� William Francis-Galvin 5CCFCtan'0f the Coinmoitweakh PC l 11c tlshburton Place, Bokton, Massachusetts 02.108-0 12 y Statement of Change of Supplemental Information Contained in Article VIII of Articles of Organization (General Laws Chapter 156D,Section 2.02 and Section 8.45;950 CMR 11,3.17) (1) Exact name of the corporation: Raker Custom Aluminum&Vinyl C any Inc. M C urrcnt registered office.address: 237 Mockingh6rd Lane Marstnns ills MA O2R4R _ _ _ ,- (number-street, city or town,state,zip code) 1(3) "l he f011owing supplerirental information has changed (ebeck appropriate box) 0 Naines-,tui addresses of the directors;president, treasurer and secretary(an address need not be spccihe(l if ills bu,�inc,s address of the officer or director is the sarne'as the principal office location): .. e President: Mark Baker Treasurer: Carol Baker , Secretary: Brett Bussiere Director(s): Mark Baker ❑ Fiscal year end: ------------- --- --- (monib,day) 0 principal office address: 521 Shootflyina Hill Road Centerville, MA. 02632 (number,street. city or toton,state, zip elide) ❑ Tl pe.of business in which the corporation intends to engage: ❑ 0ihcr: ------------ .,1 This certificate is effective at the rime and or%the date approved by the Division, unless a later eRectivr dale not inorr than '11)i1a , lions the date of filing is specified.: ---=— ---- - — ..�: � r �� . � , - . ' \V . . r � � 502883 - CA l-T t. 1 lo t I . . aoT _.._ x g s 'AA PS `�a i ran�► �� it U C�I n r _.S_�hc CAA . .� Ez rl LJ { E 1 Z [00 1110 c� _' • { 5d2883 r Lo i C F q � Y _ y N " 4 . Y • M + a . . rF _ IPT • • , t "P . L1 K—( Q O t5 l P-1L.1ezlOJl r s Y _ t . , - . 4 n .. .. qr, i S, l 1' R� / 14 .. V 27a 2� ' /6" E' -... //0. 00 4 j'K --------- — `ST;(< , LO7- 2/ 20 78� S� T aACf r�S' RE4� /0: 0 o i Oct \ o� o 0 q _ 0 o. s r , 0 F4�I" 6F 41 \ o FRANK WHITING H 4 � � . 29869 � EGIST Q' 3\\ �4 `�S c �O 4 7',ys- _ST.e�G T�.eE t��,aicTEa �L o T �G.Q•c./ q� . oN 7�S ivG.4.ti/ 4�.4�' G o c..�rEPJ L,o li�I �01 .4ccv,C,.�7z-r S�.,cv�y o.✓ f2 12 ,B,4 RA/ST.LI,1 � ..._-S.�.lo�.v� .qS _®.c �►-.✓�.�.4 Tom- �R —LL O V. /2. /9 cS5 / 3 /�d �i�/ !�P [�`, �/ CAI®E CO U S U 1 !l t 1 CONSULTANTS 3261 MAIN ST./ROUTE 6A BARNSTABLE VILLAGE, MA 02630 �•�,T� ? •�/, .3- f 584-c7� (617) 362-6133 -